At Highland Hospital in Asheville, North Carolina, mental illness was cured with a balanced diet, exercise, and a few treatments of insulin coma or electro-shock therapy. The hospital was considered cutting edge in the treatment of mental health, and was where Zelda Fitzgerald spent half her life, until she and eight others perished in a fire that destroyed Highland Hospital in 1948.

Author Lee Smith takes this fascinating place in history and weaves it with fiction through the eyes of the fictional character Evalina Toussaint. Evalina narrates her own story, beginning with her childhood. Orphaned by the death of her mother, Evalina loses her home and place in life, ending up at Highland Hospital for depression. As Evalina starts to feel at home in this place, she encounters people like Robert, a young genius who can recall the most obscure facts; Dixie, a self-proclaimed debutante who just wants to be happy being a wife and mother; and Zelda Fitzgerald, the wife of F. Scott Fitzgerald, a woman who suffered from schizophrenia and excelled in every art form she touched, yet is haunted by the career as a dancer she couldn’t have.

Smith packs this novel full of history and facts without it reading like a history textbook. When the art teacher is praising Zelda Fitzgerald’s paintings, Evalina ponders, “I am sure that she did not agree with Dr. C’s idea that women patients in general should be urged to give up their ‘unrealistic ambitions’ and be ‘re-educated toward femininity, good mothering, and the revaluing of marriage and domesticity.’” Medicine’s understanding of mental illness at that time is explained through Evalina’s treatment: she is often gardening, painting, and swimming. She is encouraged to be so active she has no time for introversion, which was believed to cause mental illness.

After the death of a friend, Evalina falls again into depression at the hospital, and is sent to the floor where insulin coma treatments are performed. Here, the purpose is to restart the mind. It’s here that Evalina witnesses how people are put into a deep sleep, tucked securely into beds so that they can’t fall out, and injected with insulin to induce a coma. Evalina describes the process: “Soon after their first shot, the patients began to perspire and drool; already, as I watched, the ones who had the higher doses went into coma and began to toss and moan, their muscles twitching. Some grabbed at the air—hands were shooting up all around the room.”

When Evalina leaves the hospital to go to music school, she ends up having another mental breakdown that brings her back to Highland Hospital, a very typical thing to happen with mental patients when leaving the structured program and going alone into the chaotic world.

“Guests on Earth” is a must for those who love historical fiction. The world of Highland Hospital that Smith creates is beautiful. Even the insulin coma ward has a haunting beauty to it. The people who reside there are genuine, and not disregarded as merely insane. The journey of Evalina and the patients of Highland Hospital as they try to acclimate to the normal world is hopeful and heartbreaking, as few truly make it back to the world and most just can’t seem to escape the things that keep them from fitting in. As Scott Fitzgerald wrote to his daughter, “The insane are always mere guests on earth, eternal strangers carrying around broken decalogues they cannot read.” (Sarah Cubalchini)